Healthcare Provider Details

I. General information

NPI: 1710679741
Provider Name (Legal Business Name): COURTNEY MARIE MOOREHEAD MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

IV. Provider business mailing address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

V. Phone/Fax

Practice location:
  • Phone: 844-533-0315
  • Fax: 513-939-0310
Mailing address:
  • Phone: 844-533-0315
  • Fax: 513-939-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0033812
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.468757
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: